Letters Letters are welcome and encouraged. They should raise points of current interest in the care of critical or high acuity patients or address topics that previously have appeared in the American Journal of Critical Care. Please be concise; letters are subject to editing for length and clarity. Include your name, credentials, title (optional), institutional affiliation, city and state, and phone number (for verification, not publication). Address letters to [email protected]. Correspondence also may be sent via eLetters from the journal’s Web site, www.ajcconline.org.
Multidisciplinary Decision Making Needed for Patient Transfers I confess to some disappointment upon reading the Garland and Connors1 article in AJCC’s September issue. First, I noted that none of the references come from nursing journals or are about intensive care unit (ICU) nurses and transfers. When I access Ovid and search the combination of Intensive Care/Intensive Care Units/Critical Care plus patient transfer plus nurse, I find 86 references since 1995. Surely at least 1 would be relevant. Second, it appears that only physicians care for ICU patients, as the “team” described is only an intensivist, a fellow, and house officers. I demonstrated in 2 observational studies2-3 that when medical ICU nurses believed there had been collaboration in making the decision to transfer a patient out of the unit, patients were less likely to die or be readmitted. It is possible that rather than looking for an objective measure that would be applicable to all ICU patients being considered for transfer, regardless of diagnosis, physicians could collaborate with other care providers on the team to gather more information and make better decisions. JUDITH BAGGS, RN, PHD Portland, Oregon FINANCIAL DISCLOSURES None Reported REFERENCES 1. Garland A, Connors Jr A F. Optimal timing of transfer out of the intensive care unit. Am J Crit Care. 2013;22(5): 390-397. 2. Baggs JG, Ryan SA, Phelps CE, Richeson JF, Johnson JE. The association between interdisciplinary collaboration and patient outcomes in a medical intensive care unit. Heart Lung. 1992;21(1):18-24. 3. Baggs JG, Schmitt MH, Mushlin AI, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med. 1999;27(9):1991-1998.
doi: http://dx.doi.org/10.4037/ajcc2013116
the care team is a valid and appropriate criticism. In fact, we do believe that nurses are key members of the ICU team, and they were included in transfer decisions, when possible. We say “when possible” because in the ICU studied, the patient:nurse ratio was most commonly 2:1 or 3:1. As a result, only about half the time was a given patient’s own nurse able to be present in the morning rounds sessions during which such decisions were most frequently made. This information should have been included in the description of the ICU care team and the decision-making process for transfers. Dr Baggs also noted that none of our references related to the role of nurses in such transfer decisions. She identified 86 indexed references she found by cross-referencing search terms. However, ours was a quantitative study in which the topic was the affect of the timing of transfer on mortality, our addition of the term timing to her search resulted in just 5 publications, none of which were actually on the topic. Whereas involvement of nurses or others in decision-making might help avoid premature transfers (the initial descending slope of the curve in our article’s Figure), it seems quite unlikely that it would influence the harm we observed from patients whose transfer is delayed due to unavailability of regular ward beds. Nonetheless, we agree that studies of nurse participation in transfer decisions are germane to the issue, and it would have been reasonable to include them in the Discussion section of our article. Finally, referring to her own publications, Dr Baggs suggests that collaborative decision-making with nurses and other members of the care team might be superior to developing objective measures of readiness for transfer. Of course this is a testable hypothesis which, to-date, has not been tested. It seems most plausible to us, however, that both approaches have something to offer. ALLAN GARLAND, MD, MA Winnipeg, Manitoba FINANCIAL DISCLOSURES None Reported
Response: Dr Baggs has taken issue with several aspects of our recent publication on timing of transfer out of intensive care unit (ICU).1 First, her observation that we failed to identify the bedside nurse as part of
464
REFERENCES 1. Garland A, Connors Jr A F. Optimal timing of transfer out of the intensive care unit. Am J Crit Care. 2013;22 (5):390-397.
doi: http://dx.doi.org/10.4037/ajcc2013593
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2013, Volume 22, No. 6
www.ajcconline.org
Downloaded from ajcc.aacnjournals.org at The University of British Columbia Library on June 22, 2015
Communication is Key to Prevent Intensive Care Unit Conflicts In response to the September editorial, “Conflict Management in the Intensive Care Unit,”1 I’d like to note that the arguments about conflict between clinical teams do not apply only to the surgical intensive care unit (ICU). Many institutions have an open medical ICU, in which the attending physician of record is a hospitalist or primary care provider and the intensivist is a consultant. This setup can lead to conflict if the ICU staff’s culture is to contact the consulting intensivist directly about changes to a patient's condition. This leads to action, without the knowledge or consent of the attending physician of record. This can be especially troublesome if the ICU team invites other consultants into the care of the patient, making it more difficult for the primary team to coordinate all of the care. The resolution is for the primary and ICU teams to negotiate their roles up front and promote open communication. Daily interdisciplinary rounds provide a forum for all care providers to make recommendations within their respective areas of expertise and for the primary team to coordinate these recommendations into a cohesive plan of action. DAVID J. GOLDSTEIN, MD Waukesha, Wisconsin FINANCIAL DISCLOSURES None Reported REFERENCES 1. Savel R, Munro CL. Conflict management in the intensive care unit. Am J Crit Care. 2013; 22:277-280.
doi: http://dx.doi.org/10.4037/ajcc2013379
www.ajcconline.org
Downloaded from ajcc.aacnjournals.org at The University of British Columbia Library on June 22, 2015
Multidisciplinary Decision Making Needed for Patient Transfers Judith Baggs Am J Crit Care 2013;22:464 doi: 10.4037/ajcc2013116 © 2013 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
Subscription Information http://ajcc.aacnjournals.org/subscriptions/ Information for authors http://ajcc.aacnjournals.org/misc/ifora.xhtml Submit a manuscript http://www.editorialmanager.com/ajcc Email alerts http://ajcc.aacnjournals.org/subscriptions/etoc.xhtml
AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2013 by AACN. All rights reserved.
Downloaded from ajcc.aacnjournals.org at The University of British Columbia Library on June 22, 2015
Multidisciplinary Decision Making Needed for Patient Transfers I confess to some disappointment upon reading the Garland and Connors1 article in AJCC’s September issue. First, I noted that none of the references come from nursing journals or are about intensive care unit (ICU) nurses and transfers. When I access Ovid and search the combination of Intensive Care/Intensive Care Units/Critical Care plus patient transfer plus nurse, I find 86 references since 1995. Surely at least 1 would be relevant. Second, it appears that only physicians care for ICU patients, as the “team” described is only an intensivist, a fellow, and house officers. I demonstrated in 2 observational studies2-3 that when medical ICU nurses believed there had been collaboration in making the decision to transfer a patient out of the unit, patients were less likely to die or be readmitted. It is possible that rather than looking for an objective measure that would be applicable to all ICU patients being considered for transfer, regardless of diagnosis, physicians could collaborate with other care providers on the team to gather more information and make better decisions. JUDITH BAGGS, RN, PHD Portland, Oregon FINANCIAL DISCLOSURES None Reported REFERENCES 1. Garland A, Connors Jr A F. Optimal timing of transfer out of the intensive care unit. Am J Crit Care. 2013;22(5): 390-397. 2. Baggs JG, Ryan SA, Phelps CE, Richeson JF, Johnson JE. The association between interdisciplinary collaboration and patient outcomes in a medical intensive care unit. Heart Lung. 1992;21(1):18-24. 3. Baggs JG, Schmitt MH, Mushlin AI, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med. 1999;27(9):1991-1998.
doi: http://dx.doi.org/10.4037/ajcc2013116
the care team is a valid and appropriate criticism. In fact, we do believe that nurses are key members of the ICU team, and they were included in transfer decisions, when possible. We say “when possible” because in the ICU studied, the patient:nurse ratio was most commonly 2:1 or 3:1. As a result, only about half the time was a given patient’s own nurse able to be present in the morning rounds sessions during which such decisions were most frequently made. This information should have been included in the description of the ICU care team and the decision-making process for transfers. Dr Baggs also noted that none of our references related to the role of nurses in such transfer decisions. She identified 86 indexed references she found by cross-referencing search terms. However, ours was a quantitative study in which the topic was the affect of the timing of transfer on mortality, our addition of the term timing to her search resulted in just 5 publications, none of which were actually on the topic. Whereas involvement of nurses or others in decision-making might help avoid premature transfers (the initial descending slope of the curve in our article’s Figure), it seems quite unlikely that it would influence the harm we observed from patients whose transfer is delayed due to unavailability of regular ward beds. Nonetheless, we agree that studies of nurse participation in transfer decisions are germane to the issue, and it would have been reasonable to include them in the Discussion section of our article. Finally, referring to her own publications, Dr Baggs suggests that collaborative decision-making with nurses and other members of the care team might be superior to developing objective measures of readiness for transfer. Of course this is a testable hypothesis which, to-date, has not been tested. It seems most plausible to us, however, that both approaches have something to offer. ALLAN GARLAND, MD, MA Winnipeg, Manitoba FINANCIAL DISCLOSURES None Reported
Response: Dr Baggs has taken issue with several aspects of our recent publication on timing of transfer out of intensive care unit (ICU).1 First, her observation that we failed to identify the bedside nurse as part of
464
REFERENCES 1. Garland A, Connors Jr A F. Optimal timing of transfer out of the intensive care unit. Am J Crit Care. 2013;22 (5):390-397.
doi: http://dx.doi.org/10.4037/ajcc2013593
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2013, Volume 22, No. 6
www.ajcconline.org
Downloaded from ajcc.aacnjournals.org at The University of British Columbia Library on June 22, 2015
Communication is Key to Prevent Intensive Care Unit Conflicts In response to the September editorial, “Conflict Management in the Intensive Care Unit,”1 I’d like to note that the arguments about conflict between clinical teams do not apply only to the surgical intensive care unit (ICU). Many institutions have an open medical ICU, in which the attending physician of record is a hospitalist or primary care provider and the intensivist is a consultant. This setup can lead to conflict if the ICU staff’s culture is to contact the consulting intensivist directly about changes to a patient's condition. This leads to action, without the knowledge or consent of the attending physician of record. This can be especially troublesome if the ICU team invites other consultants into the care of the patient, making it more difficult for the primary team to coordinate all of the care. The resolution is for the primary and ICU teams to negotiate their roles up front and promote open communication. Daily interdisciplinary rounds provide a forum for all care providers to make recommendations within their respective areas of expertise and for the primary team to coordinate these recommendations into a cohesive plan of action. DAVID J. GOLDSTEIN, MD Waukesha, Wisconsin FINANCIAL DISCLOSURES None Reported REFERENCES 1. Savel R, Munro CL. Conflict management in the intensive care unit. Am J Crit Care. 2013; 22:277-280.
doi: http://dx.doi.org/10.4037/ajcc2013379
www.ajcconline.org
Downloaded from ajcc.aacnjournals.org at The University of British Columbia Library on June 22, 2015
Multidisciplinary Decision Making Needed for Patient Transfers Judith Baggs Am J Crit Care 2013;22:464 doi: 10.4037/ajcc2013116 © 2013 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
Subscription Information http://ajcc.aacnjournals.org/subscriptions/ Information for authors http://ajcc.aacnjournals.org/misc/ifora.xhtml Submit a manuscript http://www.editorialmanager.com/ajcc Email alerts http://ajcc.aacnjournals.org/subscriptions/etoc.xhtml
AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2013 by AACN. All rights reserved.
Downloaded from ajcc.aacnjournals.org at The University of British Columbia Library on June 22, 2015
